| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
616 |
616 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
614 |
614 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
178 |
81 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,134 |
561 |
$14K |
| D1206 |
Topical application of fluoride varnish |
660 |
660 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
599 |
592 |
$10K |
| D0274 |
Bitewings - four radiographic images |
178 |
178 |
$7K |
| D0272 |
Bitewings - two radiographic images |
169 |
169 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
95 |
95 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
13 |
$2K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$759.10 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$436.15 |